Consent Form for Dental Care

Even with the highest level of medical care, there is always some risk with any anesthetic procedure. Although complications are rare, they may include injury, illness, or even death. For this reason, we take many steps to minimize this risk for each patient:

Pre-Anesthetic Bloodwork -- allows us to diagnose medical conditions that cannot be detected on physical examination before they cause a problem under anesthesia
Thorough Pre-Anesthetic History – gives us more information to help avoid anesthetic issues
Comprehensive Physical Examination on the morning of anesthesia
Certified Veterinary Technicians – our CVTs are specially educated and trained to provide the best possible care; for your pet’s best health and safety, only CVTs or DVMs monitor anesthesia in our practice
Inhalant Anesthesia – allows your pet to sleep and wake up faster, smoother, and safer
Airway Intubation – providing a secure airway during anesthesia
Careful Monitoring – dedicated certified technician monitors heart rate, breathing rate, oxygen content in blood, blood pressure, depth of anesthesia, ECG, CO2 levels, and body temperature throughout the procedure and recovery
IV Catheter and Fluids -- allows immediate cardiovascular access in case of an emergency under anesthesia, supports blood pressure and kidney function under anesthesia, decreases nausea during the recovery period, and prevents dehydration
Complete Recovery – a certified technician will stay with your pet through the recovery process
Peri-Operative and Post-Surgical Pain Control – all patients will receive pain control at the doctor’s discretion, if you have difficulty giving medications by mouth please let us know before surgery

Choose Your Option for Dental Procedures *

OPTION 1 - I prefer to be called before any additional procedures, other than emergencies. If I cannot be reached, I authorize you to proceed with all necessary dental procedures not to exceed the amount of $500 or (fill in $ amount - You will be able to select your custom amount later) above the estimate. I am aware that if the necessary procedure costs exceed this amount then the procedures will not be done. A second dental procedure would need to be scheduled at a later date to finish necessary procedures. OPTION 2 - If I cannot be reached by phone, I do not authorize any unforeseen dental procedures. I am aware that this means infected teeth will be left untreated.

Option 1 Options *

Do not exceed $500 additional Do not exceed a custom amount

I, the undersigned owner or owner's agent of the pet named above, have been informed that my pet is in need of preventive or therapeutic dental care and consent to the appropriate procedures described to me by staff veterinarians at Mountain View Veterinary Hospital. These procedures include but are not limited to the following: 1) dental prophylaxes (routine teeth cleaning and polishing), 2) extractions, 3) gingival flap surgery to close gaps left by extractions, 4) root planings, 5) dental radiographs, and/or 6) antibiotic gel implants. *

I have read and understand.

I am aware that dental procedures for animals require the use of anesthesia to: (1) maximize visualization of the gums, teeth, and oral cavity, (2) minimize movement and discomfort, and (3) provide for the safety of the pet, doctors, and hospital staff. I understand that some risks always exist with anesthesia and dental procedures, and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before these procedures are initiated. Should some unexpected life-saving emergency care be required and the attending veterinarian be unable to reach me, the staff has my permission to provide such treatment, and I agree to pay for such care. I have been informed that examinations under anesthesia often reveal abnormally loose teeth that fall out or should be extracted to prevent oral discomfort and ongoing infection of surrounding bone. I also have been informed that the loss or removal of one or more unhealthy canine teeth occasionally allows for an awkward protrusion of the tongue to one side or the other. Nevertheless, all questions and concerns I have about the recommended dental procedures have been answered to my satisfaction. I understand that an estimate of the fees for the above dental care will be provided to me and that I am encouraged to discuss all fees related to such care before services are rendered. I agree to assume financial responsibility for the remaining fees, and provide payment via cash or credit card at the time my pet is discharged. MVVH requires placement of an IV catheter to administer fluids while under anesthesia. IV fluids will aid the body in stabilizing internal organs, stabilizing blood pressure, and flushing the anesthesia out of the body more efficiently. Along with shaving the hair at the IV catheter site, we may also shave other areas including the surgical site for surgical prepping and cleansing, and also the monitor sites, so they will function properly. I agree to indemnify and hold Mountain View Veterinary Hospital harmless from and against any and all liability arising out of the performance of any of the procedures referred to above. *

I have read and understand

Consent Form for Dental Care

​Entering Your Full Name Here Will Serve As Your Digital Signature:

Entering Your Full Name Here Will Serve As Your Digital Signature: